A Guide to Alzheimer's Disease

| January 3, 2007

A Guide to Alzheimer's Disease

Are you having memory problems that seem to go beyond the ordinary, or do you see this happening to someone you love? Are there other difficulties, like struggling to follow a conversation or find the right word, getting confused in new places, or botching tasks that once came easily? Everyone has these experiences sometimes, but if they happen regularly, they may be early signs of Alzheimer's disease.

The condition strikes fear in people's hearts, and with good reason. It is the leading cause of dementia, a brain disorder that robs people of their cognitive function and eventually of their very selves. About 4.5 million Americans have Alzheimer's disease. It is the seventh leading cause of death in the United States. There is no cure, and current treatments alleviate symptoms temporarily at best. However, many new drugs are under investigation, and the first disease-altering treatments may become available in the next several years. Meanwhile, caring for someone with Alzheimer's is one of the toughest jobs in the world. It is stressful, physically and emotionally draining, and very expensive.

The information in this guide includes help for family members and caregivers, as well as for individuals with Alzheimer's. Because the disease is progressive, coping with it requires foresight and careful advance planning. This includes getting financial and legal documents in order, investigating long-term care options, and determining what services are covered by health insurance and Medicare. People in the early stages of Alzheimer's often can be partners in that planning.

In this report, you'll learn about these and other facets of Alzheimer's disease:

the destructive brain process that causes symptoms
brain imaging technology that can diagnose Alzheimer's early, improving the opportunities for symptom management
discoveries that may someday stop Alzheimer's from attacking the brain
factors that increase or may lower your risk for the disease
techniques for managing the care of people with Alzheimer's
legal and financial planning and long-term care options.

This information is designed to help ease the stress of Alzheimer's disease. With planning, patience, knowledge, and support, you can better meet the challenges posed by this disease and improve the quality of your life and that of your loved ones.

What is Alzheimer's disease?

Alzheimer's disease is a degenerative brain disorder that results in memory loss, impaired thinking, difficulty finding the right word when speaking, and personality changes (see "Warning signs of Alzheimer's disease," below). Its course is marked by a continual loss of neurons (nerve cells) in areas of the brain that are crucial to memory and other mental functions. Levels of brain chemicals known as neurotransmitters, which carry complex messages back and forth among billions of nerve cells, are also diminished. After the symptoms first appear, people live anywhere from 220 years in an increasingly dependent state that exacts a staggering emotional, physical, and economic toll on families.

There is no cure or even a firm cause or proven means of prevention. But early diagnosis is important because drugs are available that may temporarily stabilize or delay worsening of cognitive symptoms, and they work best in the early stages of the disease.

Warning signs of Alzheimer's disease

Trouble remembering things. At first, only short-term memory may be affected. The individual may forget an appointment or the name of a new acquaintance. She may also forget where she left things, or she may leave things in odd places (for example, putting her shoes in the microwave). Eventually, long-term memory also is impaired, and the individual may not recognize family members.

Mood or personality changes. The person may suddenly become angry or sad for no apparent reason. Or someone who was social and outgoing may become withdrawn. The person may also become stubborn or distrustful. Depression also often accompanies Alzheimer's disease, bringing such symptoms as loss of interest in a favorite hobby or activity, a change in appetite, insomnia or sleeping too much, lack of energy, and hopelessness.

Trouble completing ordinary tasks. Simple tasks that once caused no difficulty may become much more challenging. For example, the individual may forget how to use the oven, lock the door, or get dressed.

Difficulty expressing thoughts. It's common for people with Alzheimer's disease to have trouble with language. The individual may try describing an object rather than using its name for example, referring to the telephone as "the ringer" or "that thing I call people with." Reading or writing may also be impaired.

Impaired judgment. The individual might have trouble making decisions, solving problems, or planning. For example, he may no longer be able to balance a checkbook or pay bills.

Disorientation. We all know what it's like to be driving and momentarily forget where we're going. But those with Alzheimer's disease may get lost in their own neighborhood. They may also lose track of dates and the time.

Unusual behavior. The individual may wander, become agitated, hide things, wear too few or too many clothes, become overly suspicious, engage in unsafe behaviors, or use foul language.

Reasons for hope

Nevertheless, there are reasons for hope. Promising results of broad-based brain research have made Alzheimer's researchers optimistic about the prospects for improved treatment and prevention. Intense efforts since the 1980s have advanced scientists' understanding of the chemical changes that take place inside the brain. Key discoveries have cleared the way for pharmaceutical companies to start developing compounds that might block the disease's destructive course and cure the patient. There is also hope that scientists will someday create a vaccine to prevent and even treat Alzheimer's disease (see "Alzheimer's disease vaccine").

These prospects are exciting, but they're still a long way from providing relief for the estimated 24 million people worldwide who currently have Alzheimer's disease. The good news is that science has given health care providers a better understanding of ways to improve the day-to-day lives of people with Alzheimer's. And this growing awareness has produced an increasing number of support groups and community services around the country to alleviate families' isolation and help ease the burden of caring for those with Alzheimer's disease at home.

A surprising history

The medical profession used to consider Alzheimer's disease a rare disorder that struck in middle age. This assumption was based on a report published in 1907 by a German doctor named Alois Alzheimer. During an autopsy, Alzheimer discovered microscopic changes including abnormal neurons, tangled fibers, and clusters of nerve endings in the brain of a 51-year-old patient who had died of progressive dementia. The report attracted attention within the medical community, and thereafter, progressive dementia in a person younger than 65 was called "Alzheimer's disease."

Doctors used to believe dementia in people over age 65 was caused by cerebral atherosclerosis ("hardening" of the brain's arteries), and it was labeled "senile dementia." (Senile simply means "old," and dementia is literally "deprived of mind.") But attitudes began to change in the 1970s. Evidence accumulating from autopsy studies suggested that Alzheimer's disease was, in fact, the most common cause of dementia in older persons. Because people were living longer, health professionals and elected officials alike were paying more attention to the problems of the elderly population. As a result, the National Institute on Aging was established in 1974, with one of its primary goals to conduct and support research on memory loss.

With the 1984 publication of diagnostic criteria for Alzheimer's and other irreversible dementias, physicians began diagnosing the disease more frequently. Meanwhile, the Alzheimer's Association, founded in 1979, began raising public awareness about the disease.

The growing numbers

Alzheimer's disease is most common among people ages 65 and older, and the risk rises steadily with age. In the United States, Alzheimer's affects 40% of the population age 85 and older.

Of course, Alzheimer's affects a far greater number of people, for it takes a toll on loved ones as well as those with the disease. With the graying of America, Alzheimer's disease is a growing national problem. Today, an estimated 4.5 million Americans have Alzheimer's. If no effective treatment or means of prevention is found, an estimated 13 million Americans may have Alzheimer's disease by 2050 three times the figure today.

Most people with Alzheimer's disease are cared for at home by spouses or other family members, often for 10 years or longer. In many cases, this results in financial as well as emotional strain. For a person with Alzheimer's disease, the annual cost of home care is estimated at $76,000, including medical expenses and indirect costs such as a caregiver's time and lost wages. The resulting social burden is high. The estimated yearly cost to society for Alzheimer's disease is about $100 billion, which includes both direct and indirect costs.

Is it forgetfulness or dementia?

Regardless of age, everyone experiences occasional episodes of forgetfulness. Many people fear that a growing number of such lapses are a sure sign of Alzheimer's, but there are important differences between simple forgetfulness and dementia (see Table 1). Experts now recognize a third state called mild cognitive impairment, which falls in between normal memory function and dementia. People with mild cognitive impairment are at increased risk of developing dementia.

Table 1: Normal aging or dementia?
Physicians often use a chart like this to help differentiate between normal aging and dementia.
Normal aging	Dementia
Preserved independence in daily activities	Critical dependence on others for key daily living activities
The person complains of memory loss but can provide considerable detail regarding incidents of forgetfulness	The person complains of memory problems only if specifically asked; cannot recall instances where memory loss was noticeable
The individual is more concerned about alleged forgetfulness than close family members are	Close family members are much more concerned about incidents of memory loss than the individual
Recent memory for important events, affairs, and conversations is not impaired	Recent memory for events and ability to converse are both noticeably impaired
Occasional word-finding difficulties	Frequent word-finding pauses and substitutions
Person does not get lost in familiar territory; may have to pause momentarily to remember way	Person gets lost in familiar territory while walking or driving; may take hours to return home
Individual operates common appliances even if unwilling to learn how to operate new devices	Person cannot operate common appliances; unable to learn to operate even simple new appliances
No decline in interpersonal social skills	Loss of interest in social activities; socially inappropriate behaviors
Normal performance on mental status examinations, relative to the individual's education and culture	Below-normal performance on mental status examinations in ways not accounted for by educational or cultural factors
Diagnosis, Management and Treatment of Dementia: A Practical Guide for Primary Care Physicians Source: (American Medical Association).

Normal forgetfulness

Normal forgetfulness is neither progressive nor disabling. Such memory problems are likely to surface when you're under stress, fatigued, ill, distracted, or overloaded. Typically, you remember the forgotten information later. Like most people, you probably rely on written reminders and other memory-jogging techniques to overcome this kind of forgetfulness.

A certain increase in forgetfulness seems to be a normal by-product of aging and is perhaps a result of changes in the brain that begin around age 50, such as a gradual loss of receptors on brain cells and a decline in certain neurotransmitters. Blood flow to the brain cells falls after age 30, and this decline could also impair memory. Researchers have found that half to two-thirds of people age 50 or over have some degree of memory loss.

Researchers disagree over how much deterioration is normal. Comparisons of younger and older people's scores on memory, learning, and intelligence tests suggest that mental sharpness declines only slightly with age. But whether such comparisons are valid is questionable because timed tests may favor the younger person. The older person's information processing is a little slower: In one study, elderly people took 2040 milliseconds longer than younger people to detect gaps in circles.

Thus, the lower scores of older persons may simply reflect a slowing of their responses, not a reduction in their mental sharpness. People may require more time and effort to learn new information as they age, but once they've learned it, they retain it as well as younger people. In practical terms, slightly slower thinking is not necessarily a disadvantage. It may actually reflect more thorough reasoning and result in fewer mistakes.

It's important to note, though, that memory loss isn't inevitable. There are many things you can do to preserve or sharpen your memory, including learning memory-enhancing techniques, reducing stress, and improving your organizational techniques (for example, always writing down appointments or having a designated spot for belongings such as keys and eyeglasses). It's also important to regularly challenge your mind with activities such as reading, doing crossword puzzles, playing chess, or taking classes. Experts believe that these kinds of activities help build and maintain synapses, the small gaps between neurons that enable them to communicate with one another.

Much age-related mental decline is due to poor vision or hearing, cardiovascular disease, diabetes, sleep disturbances, alcohol abuse, depression, or medications that interfere with the mental processes. Addressing these conditions can also make a difference. In the final analysis, changes people see in themselves or a relative are far more likely to be signs of some other health problem, not early dementia.

Mild cognitive impairment

Mild cognitive impairment (MCI) is considered a transitional state between normal forgetfulness and dementia. At least one cognitive (thinking) domain usually memory is below normal or in decline. When memory is affected, the condition is called amnesic MCI. Although some people with MCI remain stable or even improve, studies show that the majority, especially those with amnesic MCI, eventually develop dementia.

Archives of Neurology Researchers who examined brain tissue removed during autopsies have provided evidence that certain telltale anatomical changes may underlie this progression. As reported in the in 2006, the researchers found that the brains of people with amnesic MCI have more neuritic plaques (clumps of degenerating neurons) and neurofibrillary tangles (abnormal twisted fibers inside neurons) than normal, but not as extensive as the pathology characteristic of Alzheimer's. About 10%15% of people with MCI progress to dementia each year. MCI becomes more common with age and affects 3%22% of people over age 65.

A person who has MCI is able to carry on daily activities without difficulty, but a particular subset of cognitive skills may be diminished. In particular, someone with MCI may show some of the following signs:

Increasing difficulty with memory or, in some cases, subtle problems in other cognitive domains, such as language, attention, spatial skills, and problem solving
Confirmation of impairment on neuropsychological tests, often manifesting as difficulty with learning and delayed recall of information compared with others of the same age and education level. In some cases, memory is normal but is less reliable than it used to be.

Dementia

With dementia, memory loss is severe enough to interfere with someone's ability to function socially and at work. The most common type of dementia is Alzheimer's disease, but there are many other types, including frontotemporal lobar degeneration, dementia with Lewy bodies, and vascular cognitive impairment, which is caused by multiple strokes that interrupt blood flow to the brain. These are some signs of dementia:

Intellectual function has declined from a previous level. This change in mental ability differentiates dementia from mental retardation.
The person is aware and alert, which differentiates dementia from delirium.
More than one type of thinking is affected. In addition to memory, at least one of the following also is impaired: personality, abstract thinking, judgment, use of language, the ability to perform complex physical tasks, or the ability to recognize objects or people. Known as global cognitive impairment, this characteristic distinguishes dementia not only from mere forgetfulness but also from such conditions as amnesia (memory loss only) and speech deficits (caused by stroke, for example).

Recognizing the symptoms

Alzheimer's disease usually is not diagnosed in the early stages, even in people who visit their primary care doctors with memory complaints. One reason is that people and their families generally underreport the symptoms. They may confuse them with normal signs of aging. Or the symptoms may emerge so gradually that the person affected doesn't recognize them or goes to great lengths to conceal them.

Recognizing symptoms early is crucial because the sooner a diagnosis is made, the more able doctors are to slow cognitive decline. Early diagnosis also allows the individual and his or her family members to plan for the future. If you or a loved one is experiencing any of the following symptoms, contact a physician.

How the brain works

A family often finds it easier to accept the Alzheimer's patient's cognitive problems than his or her behavior problems, which may make the patient seem deliberately uncooperative, spiteful, or just plain mean. But both kinds of problems are consequences of the disease. A close look at the brain reveals how memory, intellectual abilities, emotions, and behavior are connected and how they become disconnected in Alzheimer's disease.

A macro view of the brain

Neuroscientist Paul MacLean coined the term "triune brain" to describe in evolutionary terms what he viewed as the three separate but interconnected levels of the human brain: the brainstem (and cerebellum), the limbic system, and the cerebral cortex (see Figure 1). An extensive two-way network of nerves connects these three levels of the brain. Ongoing communication between the cerebral cortex and the limbic system inextricably links thinking and emotions (see Figure 2). Each influences the other, and both direct all voluntary action. This interplay of memory and emotion, thought and action is the foundation of each individual's unique personality.

Figure 1: The three levels of the brain

Three levels of the brain

The most primitive level of the brain is made up of the brainstem and cerebellum (1). The brainstem regulates the kinds of body functions you rarely stop to think about, such as your heartbeat, breathing rate, and blood pressure. The cerebellum coordinates posture, muscle tone, and skilled movements. The next level, the limbic system (2), provides the link between animal drives and rational behavior. The third level, the cerebral cortex (3), is the wrinkled "gray matter" that covers the brain. Less than a quarter-inch thick, the cerebral cortex is responsible for higher-level thought, memory, and language.

A micro view of the brain

Up close, the brain is a web of interconnecting cells called neurons. How these cells communicate and what happens when these cells die form the basis of our understanding of brain disease.

Risk factors for Alzheimer's disease

A number of factors have been linked to Alzheimer's disease. Age, heredity, sex, cardiovascular problems, and brain injury may play a part.

Age and sex

Your age itself poses some risk, regardless of whether a family member has had Alzheimer's disease. The risk usually rises after age 65 and increases in subsequent years (see Table 2). Still, Alzheimer's is not an inevitable consequence of aging.

It also appears that women have a somewhat higher rate of Alzheimer's disease than men do. However, this effect might be due not to any biological factor, but to greater longevity.

Table 2: Americans with Alzheimer's disease
About 4.5 million people in the United States have Alzheimer's disease.
Age group	People with Alzheimer's	Estimated prevalence per age group
6574	0.3 million	5%
7584	2.4 million	17%
85+	1.8 million	45%
Archives of Neurology, Source: "Alzheimer Disease in the U.S. Population: Prevalence Estimates Using the 2000 Census," August 2003.

Genetic factors

When a family member has Alzheimer's, people often wonder about their own chances of developing the disease. While heredity is a major factor in a small number of families, for most people, genetics plays only a minor role or none at all.

Cardiovascular risk factors

Many studies show that physiological conditions that harm the heart and blood vessels also increase the risk of Alzheimer's disease and vascular cognitive impairment. These include high blood pressure, high cholesterol, obesity, and smoking, which all increase the risk of stroke, a direct cause of vascular cognitive impairment. But such risk factors may also indirectly lead to Alzheimer's disease by other means.

Diabetes

People with either type 1 or type 2 diabetes face a greater risk of Alzheimer's disease and vascular cognitive impairment. Research indicates that this increase in risk may be due to a shared mechanism: a deficiency or dysfunction of insulin, the hormone that enables cells in the body to use blood sugar (glucose).

Journal of Alzheimer's Disease Brain cells need blood sugar in order to function, and in particular to execute a high-energy task such as learning a skill or forming a memory. Yet a 2005 study in the provides evidence that the brain's ability to use blood sugar may be compromised as Alzheimer's disease develops. The researchers found that insulin levels and the number of insulin receptors in the brain fall dramatically in the early stage of Alzheimer's disease, and they continue to plummet as the disease progresses. In the advanced stage of Alzheimer's disease, there are 80% fewer insulin receptors in the brain than is normal. The researchers think that the decline in insulin and insulin receptors in the brain may be linked somehow to the death of neurons and appearance of tangles in the brain the signs of Alzheimer's disease.

Head injury

Many former boxers develop a condition called dementia pugilistica (boxer's dementia) after suffering repeated blows to the head. The microscopic changes in their brains resemble those in Alzheimer's disease, which led researchers to wonder if brain injury might be a factor in the disease. Researchers discovered amyloid deposits in people who died shortly after severe head injury, especially in those with the ApoE4 gene. The authors concluded that less severe head injuries might trigger amyloid deposits in susceptible people, resulting years later in full-blown Alzheimer's.

Possible protective factors

Although no treatment is available to prevent or cure Alzheimer's, certain factors may lower your risk for it. For now, it's premature to recommend taking nonsteroidal anti-inflammatory drugs or statins to prevent Alzheimer's, but research is under way to test the effectiveness of these and other substances for preventing or delaying its onset.

Nonsteroidal anti-inflammatory drugs

Nine studies suggest that using pain relievers such as ibuprofen (Advil, Motrin, and others) or naproxen (Aleve) can lower the risk of developing Alzheimer's disease. These medications, called nonsteroidal anti-inflammatory drugs (NSAIDs), block enzymes that promote inflammation, pain, and fevers. Scientists suspect that NSAIDs protect against Alzheimer's by reducing brain inflammation that may occur during the disease's development. In addition, there is experimental evidence that ibuprofen decreases the production and accumulation of beta-amyloid.

People who reported taking ibuprofen and other nonaspirin NSAIDs lowered their risk of developing Alzheimer's by as much as 60% in a large 16-year study involving 1,828 participants, which was conducted by researchers at Johns Hopkins University and the National Institute on Aging.

But it's too early to recommend NSAIDs for Alzheimer's prevention. Because all nine studies mentioned were observational, their findings are not considered conclusive. In addition, NSAID medications have a variety of side effects; for example, frequent use of naproxen and celecoxib (Celebrex) may increase the risk of heart attack or stroke. Concern about safety led the National Institutes of Health to suspend enrollment in a large study evaluating the potential of these drugs to prevent Alzheimer's disease. However, the researchers are still following people who enrolled in the study before recruitment was suspended to learn whether the drugs can safely reduce the risk of Alzheimer's.

Statins

Archives of Neurology Several studies have found that statins, a commonly prescribed class of cholesterol-lowering drugs, may lower the risk for Alzheimer's disease. One 2000 study in the found that statins cut the risk of developing Alzheimer's disease by as much as 73%.

Such preliminary findings have paved the way for future research to test the use of statins in preventing or slowing the progression of Alzheimer's disease. A trial conducted as part of the Alzheimer's Disease Cooperative Study, with funding from the National Institute on Aging, is under way to determine whether statins can slow the progression of the disease among patients with mild to moderate Alzheimer's.

Alcohol consumption

Journal of the American Medical Association, JAMA Epidemiological studies have found evidence that moderate alcohol consumption reduces risk for Alzheimer's disease. A 2003 study in the for example, found that people over age 65 who drank up to one alcoholic beverage a day had about half the risk of Alzheimer's disease as nondrinkers. And a study reported in 2005 by researchers in New York found that resveratrol, a compound in red wine, broke down beta-amyloid in the laboratory suggesting that red wine in particular may be protective. But further study is needed. In the meantime, experts do not recommend drinking alcohol to fend off Alzheimer's disease. If you do drink, limit your consumption to two drinks a day for men and one drink for women. Heavy drinkers in the study cited above had a 22% higher risk than the nondrinkers.

Education

Epidemiologists have found that a disproportionate number of people with Alzheimer's disease are poorly educated. The reason is unknown, but it raises two intriguing questions. Does education produce biological changes in the brain, actually stimulating neurons to grow and form more synapses? Or is it socioeconomic status, rather than educational level, that makes a difference?

If education causes beneficial changes in brain structure, it's possible that an educated person could lose a certain number of neurons without a noticeable change in mental ability, while an uneducated person who lost the same number would suffer mental deficits. In effect, education might delay the onset of symptoms.

Research supports this theory. Imaging studies of people with the same degree of Alzheimer's symptoms have shown that the most educated people had less brain activity and blood flow to the brain than the least educated people. In other words, it took more brain damage to cause symptoms in the people who'd had the most schooling. Autopsies of participants in an ongoing (longitudinal) study show that among people who had the same degree of brain damage from Alzheimer's, the most educated people experienced the least severe symptoms. Socioeconomic factors may be important, too. People who grow up in poverty are also likely to be poorly educated. But they might also have dietary deficiencies or exposures to more environmental toxins that would leave them vulnerable to Alzheimer's disease later in life. The interaction among these social, economic, and educational factors is complex, further muddying the waters.

Many researchers now believe that education level is less important in maintaining a healthy brain than the habit of staying mentally active as you age. A 2002 study reported an association between frequent participation in cognitively stimulating activities (such as reading, doing crossword puzzles, visiting museums) and a reduced risk for Alzheimer's.

Enriched environment

Taking the research on intellectually stimulating activities one step further, scientists have been looking at the notion of "environmental enrichment" living in a place with a lot of interesting things to do and how this might benefit the brain. Some intriguing findings have emerged from research involving laboratory mice. Researchers have found, for instance, that mice raised in cages with running wheels, colorful tunnels, and other toys exhibit better memory function than mice raised in bare cages. What's more, autopsy studies have revealed that the mice raised in enriched environments also have "enriched" brains, with more synapses per neuron and more branches extending from their neurons.

Cell A 2005 study in looked specifically at whether environmental enrichment might prevent Alzheimer's disease in mice bred to develop the disease. Sure enough, by the time they reached old age, the mice raised from birth in the cages with plenty of toys had far lower levels of beta-amyloid peptide and amyloid deposits in their brains the physical signs of Alzheimer's disease than mice raised in a bland environment. The researchers also noticed that environmental enrichment increased the expression (activity) of genes involved with memory, neuron growth, and the generation of blood vessels to the brain. This evidence suggests that an enriched environment can change the brain in ways that may preserve memory and prevent Alzheimer's disease.

As far as people are concerned, there may never be data available to quantify the health advantages of enriching one's days with good books to read, musical instruments to play, computers as learning tools, excursions to the theater, and travel to interesting destinations. But stimulating activities make for a full life, and they may keep your brain healthy, too.

Exercise

Exercise offers an impressive array of health benefits. It helps prevent heart disease and type 2 diabetes; lowers the risk for high blood pressure, colon cancer, and breast cancer; and helps relieve insomnia, anxiety, and depression. But that's not all. Several studies suggest that exercise might also help ward off Alzheimer's disease and other forms of dementia.

Lancet Neurology, One study of 2,000 people, published in 2005 in found that those who exercised during midlife for 20 to 30 minutes twice a week were at least 50% less likely to develop Alzheimer's disease or another dementia in the following decades than people who were sedentary. Earlier, a Canadian study involving 9,000 people over age 65 found that regular exercise cut the risk for cognitive impairment by 37%. Studies of seniors in the United States and the Netherlands have yielded similar results.

Journal of Neuroscience Just how exercise may prevent Alzheimer's disease is unclear, but research on mice offers a clue. A 2005 study in the reported that mice that used their treadmills most often not only proved better able to learn how to get around test mazes than others, but also had fewer deposits of beta-amyloid in their brains. And in the environmental enrichment study described previously, the lowest levels of beta-amyloid and amyloid deposits were found in the most active mice, who spent the most time running and climbing on the toys placed in their cages.

Diet

Just as some dietary fats can protect against cardiovascular disease and others can increase the risk, several studies suggest that the same is true for Alzheimer's disease. Diets that are high in damaging saturated fats and trans fats appear to increase the risk of Alzheimer's disease, whereas diets that are high in heart-healthy monounsaturated and polyunsaturated fats appear to decrease the risk. Saturated fats come mainly from meat and dairy, and trans fats from processed foods made with partially hydrogenated oils. Sources of healthy unsaturated fats include nuts, olive oil, canola oil, and fish.

Archives of Neurology, A 2003 study in for example, followed 815 cognitively normal people ages 65 and older for four years. By the end of the study, the people who ate the most saturated and trans fats were twice as likely to have Alzheimer's disease as the people who consumed the least. However, the people who ate the most mono- and polyunsaturated fats were 70% less likely to develop Alzheimer's than the people who ate the least of these healthy fats.

Neurology Several other studies have found a benefit specifically from eating fish that is rich in omega-3 fatty acids, a type of polyunsaturated fat. Salmon, mackerel, and sardines are good sources. One 2005 study in found that people who ate fatty fish more than twice a week had a 28% lower risk of dementia and a 41% lower risk specifically of Alzheimer's disease than people who ate fatty fish less than once a month. This study did not find a protective effect from eating lean fried fish.

Neurobiology and Aging, Many unanswered questions about diet remain, however. It is unclear whether fish oil supplements are also beneficial. If fish does reduce the risk of various types of dementia, it could be because of its protective effect against cardiovascular disease. But fish may also benefit the brain directly. In a 2005 study reported in researchers found that a diet supplemented with omega-3 fatty acids limited the accumulation of beta-amyloid in the brains of mice bred to develop Alzheimer's disease. Whether people would enjoy the same benefit remains to be seen, but in the meantime, it can't hurt to replace the unhealthy fats in your diet with healthy ones.

Estrogen

For many years, doctors believed that hormone therapy during and after menopause might protect women from Alzheimer's disease: A handful of studies suggested that women who took estrogen were less likely to develop this type of dementia than those who didn't take supplementary hormones. But a large clinical trial, the Women's Health Initiative Memory Study (WHIMS), challenged this longstanding dogma.

WHIMS researchers reported in 2003 that women who took combination estrogen-progestin therapy were twice as likely to develop dementia as women who did not use hormones. The following year, the researchers revealed that estrogen therapy by itself also increased the risk. This study and others also found that women as young as 50 who used estrogen therapy, with and without progestin, were more likely to have strokes, which can cause dementia. As a result of such findings, menopausal hormone therapies now carry warning labels stating that they increase the risk of dementia.

Despite the negative findings about hormone therapy as a preventive measure, some early evidence suggests that hormone therapy or estrogen-like medications may somewhat improve memory and other cognitive functions in women with Alzheimer's disease (see "Estrogen therapy").

Diagnosing Alzheimer's disease

No blood test, brain scan, or physical exam can definitively diagnose Alzheimer's disease. And because so many conditions can produce symptoms resembling those of early Alzheimer's, reaching the correct diagnosis is complicated.

Finding a physician

It's important to find a physician experienced in Alzheimer's diagnosis. If a physician diagnoses Alzheimer's after only a cursory examination, get a second opinion. A complete evaluation by a physician experienced in diagnosing Alzheimer's is essential to exclude other health problems that could cause cognitive difficulties. Your family physician may do part of the evaluation and then recommend a neurologist, geriatrician, or other specialist to complete it. Your local Alzheimer's Association chapter, medical school, or hospital can also help identify appropriate specialists.

Before scheduling an appointment, ask what diagnostic procedures will be used. If the evaluation does not sound comprehensive (see "The evaluation process"), seek another physician. If you are unsatisfied with the evaluation, get a second opinion.

Once a diagnosis is made, find a physician experienced in providing ongoing care to meet the changing needs of someone with Alzheimer's disease. The doctor who makes the diagnosis may not be the one who will oversee the long-term care. For this purpose, the family needs to choose someone who's knowledgeable about managing dementing illnesses and able to communicate well with family members.

What to expect

A complete evaluation will take more than a day and is generally done on an outpatient basis. In most areas, the evaluation can be done locally, and tests can be spread over several days to avoid tiring the person being examined. Other specialists besides the treating physician may be involved in the evaluation, including technicians, nurses, psychologists, occupational or physical therapists, social workers, and often psychiatrists.

It will take several days before test results are reported and the physician reviews them. When the doctor discusses the findings, be prepared for an equivocal diagnosis. Physicians are often hesitant to diagnose Alzheimer's disease without first observing that the dementia is progressive. This means repeating the evaluation, usually in 612 months. At this later time, a much more confident diagnosis is sometimes possible, but when cognitive changes are gradual, the doctor may recommend repeated testing at yearly intervals.

The evaluation process

To help alleviate any stress associated with your visit to the physician, it's best to be as prepared as possible. For instance, be sure that whoever goes with the individual being evaluated is familiar with his or her medical history, current symptoms, and concerns. It's always helpful to write down in advance any issues you want to mention at the visit. Particularly if the person is in an advanced stage of dementia, you may want to bring a cassette or CD player with headphones to play calming music, or a familiar soft item that can be stroked or held.

Is it Alzheimer's or another dementia?

For physicians and families intent on pinning down a diagnosis, one major factor that complicates the clinical picture is the existence of so many kinds of dementia. More than 50 conditions can mimic or cause dementia. Alzheimer's disease is by far the most common intractable condition. But other causes of irreversible dementia include blood vessel disease (vascular cognitive impairment, Binswanger's dementia), other degenerative disorders (frontotemporal lobar degeneration, Parkinson's disease, Huntington's disease), slow-growing brain tumors, or infections of the central nervous system (Creutzfeldt-Jakob disease, AIDS dementia, neurosyphilis).

In some types of dementia, treatment will improve mental functioning, and in a small percentage, the dementia is completely reversible if treatment begins before permanent brain damage occurs. That's why it is important to report to a doctor any signs of dementia early in the process.

Reversible dementias

Reversible dementias are often easier to diagnose than irreversible dementias because they are usually accompanied by other, obvious symptoms. In the following conditions or situations, however, dementia may be the primary, or even the only, symptom. Proper treatment may improve or even restore cognitive functioning.

Irreversible dementias

Although there are many causes of irreversible dementia, the following conditions are among the most common. In some cases, prompt treatment can prevent further damage, but lost cognitive functioning cannot be restored.

The search for therapies

This is an exciting time in Alzheimer's research. You may have heard or read about a variety of therapies on the horizon, some in the form of new drugs that may be able to cure the disease by blocking the chain of events that underlie its destructive process. Still, while scientists believe they are finally beginning to close in on this elusive disease, a cure is years away.

There is currently no treatment that prevents or stops cognitive deterioration. Available medications can only alleviate symptoms temporarily. The hope and expectation is that ongoing research efforts will yield therapies that bring about better, longer-lasting improvements in memory and other cognitive functions.

A number of medication options do exist for behavior problems, such as outbursts of anger, which sometimes develop in someone with Alzheimer's. These are best used in conjunction with environmental changes, such as simplifying the home environment (see "Techniques for living with someone with Alzheimer's disease").

Drugs for memory and cognitive function

The FDA has approved five drugs for the treatment of Alzheimer's disease: donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne, formerly Reminyl), tacrine (Cognex), and memantine (Namenda). All these prescription medications work by affecting particular chemicals in the brain and offer modest improvements in memory and cognitive function in some people with Alzheimer's (see Table 3).

Table 3: Medications for memory and cognitive symptoms
Generic name	Brand name	Side effects	Comments
donepezil	Aricept	Nausea, diarrhea, dizziness, insomnia, vomiting, muscle cramps, fatigue, loss of appetite, weight loss	Most widely prescribed drug in its class. Adverse effects are often mild and decline with continued use. Should be taken in the evening, just before going to bed. Can be taken with or without food.
galantamine	Razadyne	Nausea, vomiting, loss of appetite, weight loss, diarrhea, dizziness	Side effects are usually gastrointestinal and occur in early weeks of treatment. Taken twice daily, with morning and evening meals.
memantine	Namenda	Confusion, anxiety, back pain, painful urination, cough, insomnia, irritability, nausea, nervousness, joint pain, shortness of breath	Prescribed for moderate to severe Alzheimer's disease. Tell your doctor if you have kidney disease or urinary tract problems because this drug can make these conditions worse.
rivastigmine	Exelon	Nausea, vomiting, loss of appetite, weight loss, dizziness, fainting, indigestion, fatigue	Associated with significant nausea, vomiting, and weight loss. If you have stopped taking the drug for more than several days, don't resume taking it without first consulting a physician.
tacrine	Cognex	Liver toxicity, nausea, vomiting, diarrhea, loss of appetite, muscle pain, loss of coordination, indigestion	Still available, but rarely prescribed because it can cause liver damage.

Donepezil, rivastigmine, galantamine, and tacrine belong to a class of drugs called acetylcholine esterase inhibitors. They work to raise the levels of acetylcholine in the brain, because a deficiency in this neurotransmitter is believed to account for the memory problems of Alzheimer's disease. They seem to work by blocking an enzyme that destroys acetylcholine, which presumably makes more acetylcholine available for transmitting impulses from one brain cell to another. The drugs are effective for people with mild to moderate Alzheimer's disease. Tacrine is rarely used because it's been associated with severe liver problems.

Only about 30%50% of the people who take this class of drugs show benefits. These medications may temporarily stabilize or improve memory problems and other cognitive symptoms. For example, one 2001 study found that taking donepezil for at least 9 months postponed a patient's need to move to a nursing home by about 21 months.

Memantine has a different mode of action. It is an NMDA (N-methyl-D-aspartate) antagonist it works by blocking glutamate, another neurotransmitter, from attaching to NMDA receptors in the brain. This is beneficial because glutamate is an excitotoxin, a neurotransmitter that usually activates neurons but in excessive amounts can destroy them. Research suggests that excitotoxins may cause some of the neuron degeneration that occurs with Alzheimer's disease (see "Antioxidants").

Memantine is used to treat symptoms of moderate to severe Alzheimer's disease. Several studies show that people in this stage of Alzheimer's who took memantine had better scores on tests of cognitive functions and daily functioning than did similar people who took a placebo. Studies are under way to see if memantine can also help people with mild to moderate symptoms.

Medications for behavior problems

Brain damage influences the way people act and react. As comprehension falters, emotional and behavior problems can soar. When the environment seems too confusing and overwhelming, someone with Alzheimer's may become angry or even violent. Although no treatment can halt the cognitive deterioration of Alzheimer's, there are ways to diminish or even resolve some behavior problems. For example, simplifying the environment, establishing a routine that places minimal demands on the individual, and using simple management techniques have all proved effective (see "Techniques for living with someone with Alzheimer's disease").

Sometimes behavior disturbances are rooted in a medical problem. Agitation, for example, may signal physical discomfort. When an undesirable behavior appears suddenly or the person fails to respond to management techniques, he or she should be evaluated by a physician. Treatment of an underlying condition sometimes resolves what appeared to be solely a behavior problem. For example, relieving neck pain caused by arthritis might stop a person from wandering at night.

Behavior management alone is not always sufficient. In some cases, a physician may prescribe psychiatric medications. Try not to expect immediate results, because physicians usually begin with a low dose and increase it gradually. Care is required because psychiatric medications can produce serious side effects, particularly in older people.

In addition, some medications, such as antidepressants, must be given for several weeks before their benefits become apparent. Keep in mind that individual responses to these medications vary considerably. The same drug that helps one person may not be effective or may even worsen symptoms in another individual.

Three classes of drugs may be used to treat emotional and behavior problems: antidepressants, anti-anxiety drugs (also called minor tranquilizers), and antipsychotics (also called major tranquilizers or neuroleptics).

Therapies under investigation

The goal of future Alzheimer's therapies is to prevent the loss of synapses and neurons in the areas of the brain involved in memory and cognition. Only then can scientists slow the course or arrest the progress of the disease. Because a complex and long-term series of events is believed to cause Alzheimer's disease, researchers are investigating several compounds that intervene in this destructive process by different means.

Anti-amyloid drugs and antioxidant drugs offer two particularly promising strategies. Each would target a process thought to be central to the loss of synapses and nerve cells. Anti-amyloid drugs would block the production of beta-amyloid, which many scientists believe sets off the destructive cascade of events that leads to neuron death. The antioxidant drugs could reduce the neuron damage caused by free radicals. Another promising area of research involves the use of stem cells to replace dying cells with healthy ones.

For the caregiver

Alzheimer's disease has a profound emotional impact on the family. Fear, denial, anger, resentment, guilt, embarrassment, and grief are all normal reactions. Getting a diagnosis can be an overwhelming experience, and when the diagnosis is uncertain, the family may feel suspended between hope and despair. In either case, it's important that family members not succumb to inaction because, as difficult as it may seem, several vital issues must be addressed immediately. Each situation is different, but family members must plan for the future. And people in the early stages of Alzheimer's should be encouraged to participate in the process. The following discussion outlines basic matters that need to be addressed.

Legal decisions

There will come a time when the person with Alzheimer's can no longer manage his or her affairs. Do not assume that you'll have advance notice. Alzheimer's disease is unpredictable, and the person whose cognitive problems seem mild may unexpectedly make irrational decisions with disastrous consequences. If possible, legal documents should be executed while the person is still competent.

Financial matters

Eventually, someone must take over the mundane task of paying bills and managing the financial affairs of anyone with Alzheimer's disease. If you don't already have access to all bank and investment accounts, you'll need a durable power of attorney that authorizes banks and brokerage firms to add your name to the person's accounts (see "Legal competence"). The wording of joint accounts matters; an account for "John Smith and Mary Jones" may require both signatures on all transactions, while either person's signature would be sufficient were the account for "John Smith or Mary Jones." Make sure that only one signature is required to avoid problems when the individual becomes incapacitated.

Stories of people with Alzheimer's disease giving away money to strangers, ordering expensive items, paying shady contractors for unnecessary repairs, and hiding large sums of cash around the house are all too common. To prevent a financial disaster, the spouse or another trusted individual should take control of the person's checkbook and credit cards as soon as the person's judgment is faulty. A financial planner may be able to offer guidance and assistance.

Explaining the condition

What should you tell someone who has Alzheimer's? Most experts say if the person asks what's wrong, you should be honest; knowing that the problem is a disease, not "insanity," is often a relief for the person affected. Telling someone who has not asked may be helpful, particularly if the person appears troubled about his or her condition. You may well be the person who knows the best way to handle the situation. Generally, though, it's best for the physician to explain the diagnosis to someone. New information doesn't always "stick," however, so don't be surprised if someone with Alzheimer's continues to ask what's wrong. In such cases, you can offer a reassuring but brief explanation.

You may also need to take some time to talk to family and friends. Individuals with Alzheimer's disease often look quite healthy in the early stages of disease, and people outside the household may be unaware that anything is wrong. But it's important to tell other family members and friends about the diagnosis as soon as possible, for two reasons. First, they need to know both that any unusual behavior is caused by disease, not by "craziness" or "meanness," and that they'll need new ways of responding as the person's cognitive abilities decline. Second, you and any other caregivers need emotional support and practical help from others (see "Tips for caregivers and friends").

Tips for caregivers and friends

Get organized. Call a family meeting to decide what kind of care is needed and who should give it or research it. Anyone who can't attend in person should try to do so by phone. Try to put aside differences so the focus stays on your loved one's needs. Make a list of what needs to be done and who can do it. While it's helpful to have one person take primary responsibility, everyone should offer to take on specific tasks.

Ask for help. Try to find out whether your loved one already has an informal network of support. Do any friends and neighbors stop by to visit or lend a hand? If you ask them to do so, many people may be willing to help more formally or call you if anything seems amiss.

Offer support. If you're not the main caregiver, ask that person how you can help. Offer specific suggestions. For example, could you take over for a weekend or vacation? Could you provide or coordinate certain services, such as housecleaning or transportation to doctor's appointments? If you're the main caregiver, spell out what needs to be done and what sort of help you require. Don't try to do everything yourself "because it's easier." Let other people step up to the plate. When someone offers help, accept it. If no one offers help, ask for it. Write out a list of smaller tasks that people could do, such as cooking an occasional dinner or running errands, and dole these out. Or simply ask others to check off what they can do.

Collect medical information. Keep a health care file that includes information on the patient's current ailments, medications, allergies, medical history, specialists seen, and treatments.

Obtain respite care. Regular respite care from professionals, family, and friends can give you much-needed breaks. Find out if there are any adult day care services available in your community.

Join a support group. Support groups allow you to talk out frustrations with other people in your situation and get helpful ideas. Some of these groups are available online; others are run by the Alzheimer's Association, local hospitals, senior centers, or community groups.

Take care of yourself. Eat well, get enough rest and exercise, and pursue activities that bring you pleasure. If it's too hard to find the time, consider getting extra help with some household chores.

Coping with daily challenges

The abilities of someone with Alzheimer's can fluctuate from day to day, or even hour to hour, which makes the caregiver's job all the more difficult. Often, the person's abilities wax and wane for the same reasons that a healthy person's abilities fluctuate: fatigue, anxiety, discomfort, or medications. Other illnesses may also play a role.

Equally confusing may be a seeming inconsistency in an individual's abilities. He or she may be able to perform a complex task, but not a simple one. Family members may suspect the person is not trying hard enough or is being deliberately uncooperative when, in fact, the uneven loss of abilities is explained by the disease process itself.

Some techniques can improve the quality of life for both patient and caregiver (see "Techniques for living with someone with Alzheimer's disease"). For example, by breaking an activity into simple steps and talking the person through it one step at a time, you can turn a complicated task such as getting dressed into a manageable one.

Techniques for living with someone with Alzheimer's disease

Communication

Use simple phrasing and short sentences, but be careful to avoid talking to the person as if he or she is a child.
To get the person's attention, begin by using his or her name.
Be patient. Give someone with Alzheimer's time to complete a sentence or thought, and try not to interrupt.

Bathing

Follow the person's old routines as much as possible.
Prepare everything in advance.
Lay out towels, soap, shampoo, and clothes. Have the water ready and at the right temperature before bringing him or her into the bathroom.
Avoid discussing whether a bath is needed. If the person refuses to get into the tub or shower, be flexible and suggest an alternative. If all else fails, try again later.
Be calm, gentle, and reassuring. If the person seems disturbed at this invasion of privacy, cover portions of his or her body with a towel.
Encourage him or her to do as much as possible without hands-on help. Talk through each step.
Check the skin for rashes and sores. Use powder, cornstarch, or body lotion on dry skin.
Safety tips: Use rubber tub mats, tub seats, grab bars, nonslip bathmats, etc. Do not use bath oil or products that make the tub slippery. Put razors and electrical appliances out of reach. Take the lock off bathroom doors.

Dental care

Prepare the toothbrush and demonstrate how to brush.
If the person will not brush and refuses assistance, try a foam applicator or a cloth moistened with mouthwash.

Dressing and grooming

Consider the person's past grooming habits, but keep grooming simple to avoid frustration.
Avoid forcing the person to choose what to wear. Remove clothes that are out of season or seldom worn.
Try to establish a routine in which you help the person dress at the same time each day.
Select simple clothing the person can manage easily without assistance. Avoid buttons, hooks, snaps, and ties.
Lay out clothing in the order that it should be put on.
Safety tips: Avoid shoes with slippery soles, pants or dresses that are too long or full, and long or full sleeves that may catch on doorknobs or furniture.

Mealtimes

Playing with food may be a signal that the person has too many choices. Put one utensil on the table and one food on the plate at a time.
Reduce sensory confusion at meals: Make sure the area is well lit. Use a plate color that contrasts with the food. Remove condiments from the table.
Eliminate distractions. Make sure the person is comfortably seated and doesn't need to use the bathroom.
Cut food into small pieces. If he or she chokes easily, switch to soft foods. Curved spoons, divided plates, and straws can make self-feeding more manageable.
Serve foods containing fiber to help prevent constipation.
Safety tips: Don't serve food or drink that is too hot. Remind the person to eat slowly and chew each bite thoroughly. If eating nonfood items becomes a problem, keep things like dog biscuits and flower bulbs out of sight.

Toileting

Put a colorful sign or reflective tape on the bathroom door to make it easy to find.
Buy slacks and pants with elastic waists, which are easier to manage than snaps and buttons.
Keep a diary of when the person urinates and has bowel movements, and remind him or her to use the bathroom at these intervals. Restlessness or agitation may indicate bladder or rectal fullness.
Help the person get into a comfortable position on the toilet.
If the person has trouble urinating, have him or her blow bubbles through a straw in a glass of water.
Restrict fluids two hours before bedtime. A portable commode or urinal bottle at the bedside may be helpful.
Use incontinence aids such as disposable briefs, pads to protect furniture, and condom catheters for men.
Try to be calm and understanding when accidents occur.

Sleeping

Discourage long naps during the day.
An afternoon walk or other exercise may promote a better night's sleep.
The sleeping area should be quiet and dim, but not completely dark. Keep a night-light on in the bedroom (and in the bathroom).
Be sure the person avoids caffeine after about 1 p.m.
Safety tips: Place locks near the bottom of doors leading outside. Lock all outside windows, and place a gate on stairs.

Activity

Observe how much activity the person can tolerate. Some may still enjoy a meal out or a social gathering, but others may become overstimulated or anxious.
Look for signs that the person is becoming frustrated. If so, turn the person's attention to another activity or offer help.
Provide opportunities for exercise, outdoor walks, and rides in the caractivities that people with Alzheimer's tend to enjoy.
Focus on variations of activities the person enjoyed before becoming ill. If he or she liked cooking, for instance, he or she may be able to wash vegetables.
Eat well, get enough rest and exercise, and pursue activities that bring you pleasure. If it's too hard to find the time, consider getting extra help with some household chores.

Finding help and support

Families often complain that physicians don't adequately explain what they need to know. To avoid feeling isolated, learn everything you can about the disease and about dealing with the person who has Alzheimer's. An excellent place to start is the Alzheimer's Association (see "Resources"), an organization that helps families cope with the demands of the disease. It has assembled a wealth of information from health professionals and caregivers, including practical guides for managing nearly any problem you might encounter.

The Alzheimer's Association organizes family support groups where caregivers share their problems and solutions. It also connects families with community resources, including adult day care programs (many of which are specifically geared toward patients with dementia), in-home respite services, and other supportive activities.

Fast fact

Alzheimer

According to the Alzheimer's Association, relatives and friends provide about three-quarters of caretaking, while paid care makes up the remainder.

Caregivers are often guilty of trying to shoulder the burden alone because they are too shy, proud, or afraid to seek help. All too often, they wear themselves out and become depressed or ill. Caring for someone with Alzheimer's is a major undertaking that is beyond the resources of a single person. It's essential that you care for yourself by getting away from your responsibilities from time to time and, if you suspect that you're becoming depressed, seeking professional help. You also need to recognize your own limits. The time may come when you can no longer provide in-home care and must move the person to a long-term residential care facility (see "Long-term residential care").

Anticipating the future

Physicians are sometimes reluctant to discuss in much detail what the future holds for someone with Alzheimer's disease. Their reticence is understandable. It's impossible to predict exactly how the disease will affect an individual because the symptoms and rate of progression vary. Some people develop severe psychiatric problems; others do not. A symptom can show up early or not appear until much later.

For some people, the decline is slow and gradual over a decade or longer; others experience a rapidly downhill course that ends in death within three years. The symptoms are also influenced by the person's intellectual abilities before the illness sets in, and by other health problems, personality, coping skills, and family support.

The five stages of Alzheimer's

One way of describing Alzheimer's disease is to divide it into five stages.

Long-term residential care

There may come a time when it is too difficult for you to care for your loved one at home. As the disease progresses, your job will become increasingly difficult despite a variety of community services to the point where long-term residential care may be the most responsible option.

Making the decision

As you come to terms with residential care, you may grapple with feelings of guilt that you're abandoning the person. You may assume incorrectly that people who wind up in nursing homes were discarded by their families. But the truth is just the opposite. Most families exhaust every other option before resorting to this type of arrangement, and, contrary to popular belief, most families do stay connected to the individual and visit often. You can also draw comfort in knowing that there are an increasing number of good programs that specialize in care and treatment of people with Alzheimer's disease.

Better care for people with Alzheimer's disease

Residential care facilities with programs for people with dementia have special features that make life easier for them. For instance, many newer facilities are designed to limit noise and have enhanced lighting to help reduce the effects of sundowning. Ample walking space accommodates wandering and diminishes the sense of being locked in. Outdoor courtyards may be designed with natural barriers, such as shrubs, so people with Alzheimer's disease feel as through they have free rein.

To give residents a greater sense of control, there may be cues to help orient them throughout the facility. Hallways may be color-coded, or "memory boxes," showing pictures or other mementos, may be affixed to patients' doors to help them find their rooms.

Many of these facilities strive to keep people with Alzheimer's active and offer a wide array of activities that involve all residents at different levels of ability. The activities should be set up so they provide some meaning and enjoyment to the individual without too much stimulation or pressure to learn. Some examples include participating in arts and crafts projects, going through family photographs, engaging in appropriate exercise, singing, dancing, or listening to music. Even doing chores, such as folding laundry, may be enjoyable for some but meaningless to others.

There has also been a shift in the general philosophy of caring for people with dementia. In the past, the general consensus was that they should be continually oriented to reality. For instance, if a person talked about visiting a sister who had died, the caregiver would remind the person what year it was and that the relative wasn't alive. Experts recommended responses like "No, I'm not your daughter, I'm your nurse."

Experts now believe that these efforts are futile and only frustrate the individual. Today, the preferred approach is to validate the person's feelings. For instance, responses like "You must really love her" to a man who talks about his dead wife, rather than, "She died 10 years ago," fosters emotional well-being. Repeated validation may also curb some behavior problems associated with frustration.

Types of facilities

Four general types of living arrangements are available for people with more advanced Alzheimer's disease. Because many high-quality centers have waiting lists, it's important to investigate a variety of options early in your planning, even if you're not yet ready to place your family member outside the home (see "Evaluating a long-term care facility").

Evaluating a long-term care facility

Keep in mind that not all specialized Alzheimer's care is equal. When you visit a center, try to determine what makes it unique. For up-to-date information on the wide variety of options available and how to evaluate them, contact the Alzheimer's Association and ask for its guide (see "Resources").

When you visit a facility, ask plenty of questions, such as these:

How is the program geared specifically for people with Alzheimer's disease?
Are the caregivers trained in the treatment of Alzheimer's?
Is it a homelike environment?
Are residents engaged in meaningful activities?
Does the facility incorporate design features that can be helpful to those with Alzheimer's, such as enhanced lighting, color-coded hallways, and plenty of walking room?
Is the environment safe? How secure is it for people who wander?
How would an upset resident be handled?
How many people live there? What's the ratio of staff members to residents?
Can medical care be given on site if needed? Who provides it? Skilled nurses? Visiting physicians?
What personal items can the resident bring?
Are skilled professionals including registered nurses, licensed practical nurses, and certified nursing assistants on duty at all times?
How long and often may family members visit?
What's the cost? Does the facility require you to pay privately?
If the patient needs to change to Medicaid funding after a few years, will he or she be able to remain at the facility?
Under what circumstances would a resident be required to leave?

Because the average cost of long-term care is $34,860 a year for an assisted-living facility and $74,095 a year for a private room in a nursing home, you'll have to investigate payment options. Aside from Medicaid, there is no national government program that funds long-term residential care. Medicaid is administered at the state level and covers only those who are impoverished. It's not uncommon for people to pay for their own care, often until they use up their resources and then become eligible for Medicaid. In some instances, usually if the person with Alzheimer's is also suffering from an acute illness, Medicare may cover a short-term living arrangement for up to 150 days. Your local Alzheimer's Association chapter is an excellent place to start identifying possible sources of assistance (see "Resources").

Glossary

acetylcholine: A neurotransmitter in the brain that is in low supply in people with Alzheimer's disease.

agnosia: An impairment of sensory perception.

amyloid precursor protein (APP): A normal brain protein that, when fragmented under certain circumstances, produces beta-amyloid.

aphasia: An impairment in the ability to use language.

apolipoprotein E (ApoE): A cholesterol-carrying protein that may be involved in Alzheimer's disease.

apraxia: An impairment in motor skills and coordination.

beta-amyloid: An abnormal protein deposited in the brain in Alzheimer's disease.

catastrophic reaction: Strong emotional reaction to a minor event.

cholinergic neurons: Nerve cells that produce acetylcholine.

Creutzfeldt-Jakob disease: A rare, rapidly progressive dementia caused by an infectious agent known as a prion.

delirium: Mental impairment with altered consciousness.

dementia: Impairment of memory and other cognitive abilities.

dopamine: A neurotransmitter in the brain involved in the regulation of movement.

excitotoxins: Brain chemicals that in excessive amounts can damage neurons.

free radicals: Reactive molecules that can damage tissue.

frontotemporal lobar degeneration: A brain disorder that can cause dementia, aphasia, neurotic behavior, and gradual changes in personality and emotional control.

Huntington's disease: An inherited disorder characterized by involuntary writhing movements and dementia.

infarct: An area of dead or dying tissue caused by lack of circulation.

limbic system: An area of the brain containing the amygdala and hippocampus; involved in memory and emotions.

mild cognitive impairment: A condition in which memory or, less commonly, another cognitive function is below normal but does not interfere with daily functioning. Considered a transitional state between normal forgetfulness and dementia.

neuritic plaques: Clumps of degenerating neuronal axons and dendrites surrounding an amyloid core that are found in Alzheimer's disease.

neurofibrillary tangles: Abnormal twisted fibers inside neurons in Alzheimer's disease.

neurons: Nerve cells, such as those in the brain.

neurotransmitters: Chemicals that transmit nerve impulses from one neuron to another.

normal-pressure hydrocephalus: A condition characterized by an excess of cerebrospinal fluid in the brain; can cause symptoms of dementia, loss of bladder control, and difficulty walking.

Parkinson's disease: A movement disorder resulting from dopamine deficiency; dementia occurs in 15%20% of cases.

plaques: See neuritic plaques.

prion: The smallest known infectious agent; unlike a virus or bacterium, it's made up entirely of protein and contains no nucleic acid.

serotonin: A neurotransmitter in the brain that's involved in regulating sleep and sensory perception. A lack of serotonin has been linked to depression.

sundowning: The appearance or worsening of behavior problems in the evening.

tangles: See neurofibrillary tangles.

tardive dyskinesia: Involuntary writhing movements of the facial muscles and tongue caused by high doses of antipsychotic drugs over long periods of time.

vascular cognitive impairment: Dementia caused by numerous infarcts, caused by a series of tiny strokes. Also called vascular dementia and multi-infarct dementia.

Resources

Organizations

Administration on Aging www.aoa.gov Washington, DC 20201 202-619-0724 800-677-1116 (toll free)

An agency of the Department of Health and Human Services, AoA provides extensive listings of national and regional resources and services for older persons. Includes a toll-free Eldercare Locator to assist in finding services.

Alzheimer's Disease Education and Referral Center www.alzheimers.org P.O. Box 8250 Silver Spring, MD 20907 800-438-4380 (toll free)

A service of the National Institute on Aging, ADEAR provides information on such topics as research, treatments, and local resources.

Alzheimer's Association www.alz.org 225 N. Michigan Ave., 17th floor Chicago, IL 60601 800-272-3900 (toll free)

The association funds research and provides educational material, counseling, referral services, and emotional support to assist caregivers. It is also a rich source of information on caregiving. Local chapters in all 50 states and in U.S. territories organize community-based services such as support groups, day care centers, and case management.

The John Douglas French Alzheimer's Foundation www.jdfaf.org 11620 Wilshire Blvd., Suite 270 Los Angeles, CA 90025 310-445-4656

The mission of the French Alzheimer's Foundation is to fund scientific and medical research into the cause, cure, and prevention of Alzheimer's disease. Information on treatments under study is available on the Web site.

Books

Alzheimer's Disease Paul Dash, M.D., Nicole Villemarette-Pittman, Ph.D. (Demos Medical Publishing, 2005)

Recommended by the American Academy of Neurology, the book discusses the causes, diagnosis, and treatment of Alzheimer's disease.

A Caregiver's Guide to Alzheimer's Disease: 300 Tips for Making Life Easier Patricia R. Callone, M.A., M.R.E., Connie Kudlacek, B.S., Barbara C. Vasiloff, M.A., Janaan Manternach, D.Min., and Roger A. Brumback, M.D. (Demos Medical Publishing, 2005)

Written by members of the Alzheimer's Association Midlands Chapter, this book offers practical information for patients, caregivers, and families on Alzheimer's disease, including the medical, legal, and financial issues.

There's Still a Person in There: The Complete Guide to Treating and Coping with Alzheimer's Michael Castleman, Dolores Gallagher-Thompson, Ph.D., and Matthew Naythons, M.D. (Perigee, 1999)

Offers a sensitive approach with a step-by-step plan for treating and caring for someone with Alzheimer's disease.

The 36-Hour Day: A Family Guide to Caring for Persons With Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life Nancy L. Mace, M.A., and Peter V. Rabins, M.D., M.P.H. (Warner Books, 2001)

A handbook for caregivers.

Review Date: 2007-01-01

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